Citation NR: 9731934
Decision Date: 09/18/97 Archive Date: 09/23/97
DOCKET NO. 93-11 937 ) DATE
)
)
On appeal from the
Department of Veterans Affairs Regional Office in St.
Petersburg, Florida
THE ISSUE
Entitlement to service connection for post traumatic stress
disorder.
REPRESENTATION
Appellant represented by: American Legion
ATTORNEY FOR THE BOARD
T. Reichelderfer, Associate Counsel
INTRODUCTION
The veteran served on active duty from October 1966 to June
1970 and from April 1971 to November 1973.
This appeal arises from a rating decision of August 1992 from
the St. Petersburg, Florida, Regional Office (RO). The
veteran perfected an appeal to this decision and in a January
1995 decision by the Board of Veterans’ Appeals (Board), the
case was remanded to the RO for further evidentiary
development. The case has been returned to the Board for
consideration.
CONTENTIONS OF APPELLANT ON APPEAL
The veteran contends, in essence, that he has post traumatic
stress disorder (PTSD) due to his service in Vietnam.
DECISION OF THE BOARD
The Board, in accordance with the provisions of 38 U.S.C.A.
§ 7104 (West 1991 & Supp. 1997), has reviewed and considered
all of the evidence and material of record in the veteran's
claims file. Based on its review of the relevant evidence in
this matter, and for the following reasons and bases, it is
the decision of the Board that the preponderance of the
evidence is against the claim for service connection for
PTSD.
FINDINGS OF FACT
1. All evidence necessary for an equitable disposition of
the veteran’s claim has been developed.
2. PTSD has not been clearly diagnosed.
CONCLUSION OF LAW
The criteria for service connection for PTSD are not met.
38 U.S.C.A. § 1110, 5107 (West 1991); 38 C.F.R. § 3.304(f)
(1996).
REASONS AND BASES FOR FINDINGS AND CONCLUSION
Background
Initially, the Board finds that the veteran's claim is "well
grounded" within the meaning of 38 U.S.C.A. § 5107(a) (West
1991); that is, a plausible claim has been presented.
This case was remanded to the RO in January 1995 for
examination by a board of two Department of Veterans Affairs
(VA) physicians to determine whether the veteran had PTSD.
The report of an August 1996 VA psychiatric examination
indicates that an evaluation was conducted by a single VA
physician. In November 1996, the veteran entered the VA
Medical Center at Lake City, Florida, and shot a VA police
officer, several computer monitors, and a television set.
The record indicates that the RO attempted to schedule an
examination by a board of physicians to comply with the
Board’s remand. However, the Medical Center responded that
the veteran had been moved to Jacksonville, Florida, and that
a physician or board of physicians could not be found at that
location to complete the examination. Since a VA psychiatric
examination was performed that is fully adequate for rating
purposes and further examination of the veteran is not
possible, the RO complied with the examination requirements
of the Board’s January 1995 remand.
Following the Board’s January 1995 remand, the veteran was
hospitalized at the VA Medical Center at Lake City, Florida,
from November 15, 1995, to December 15, 1995. The discharge
summary for this hospitalization contains detailed findings
and diagnoses based on one month of psychiatric
hospitalization. The discharge summary is therefore fully
adequate for rating purposes without the need for further
examination. 38 C.F.R. § 3.326 (1996).
Since the examination that was conducted in response to the
Board’s January 1995 remand substantially complied with the
requirements of the remand and the VA hospital discharge
summary is fully adequate for rating purposes, there is no
further requirement to remand this case to the RO for another
examination of the veteran. Additionally, the veteran has
not indicated that additional relevant evidence of probative
value may be obtained which has not already been sought and
associated with his claims folder. Accordingly, the Board
finds that the duty to assist him, as mandated by 38 U.S.C.A.
§ 5107(a) (West 1991), has been satisfied.
Service connection may be granted for disability resulting
from disease or injury incurred in the line of duty in
service. 38 U.S.C.A. § 1110 (West 1991). The provisions of
38 C.F.R. § 3.304(f) (1996) govern the granting of service
connection for PTSD. This regulation provides that service
connection may be granted where there is "a clear diagnosis
of the condition, credible supporting evidence that the
claimed inservice stressor actually occurred, and a link,
established by medical evidence, between current
symptomatology and the claimed inservice stressor." 38
C.F.R. § 3.304(f) (1996).
The DD-214 indicates that the veteran served in Vietnam from
September 1967 to September 1968.
A report of medical examination, dated in January 1968, notes
that the psychiatric evaluation of the veteran was normal.
The report of medical examination, dated in January 1970 for
separation, notes that the psychiatric evaluation of the
veteran was normal.
A report of medical examination, dated in April 1971, notes
that the psychiatric evaluation of the veteran was normal. A
neuropsychiatric screening report, dated in July 1973, notes
that there was no evidence of psychosis or neurosis. The
impression was no formal diagnosis. An October 1973 report
of medical examination indicates that the psychiatric
evaluation of the veteran was normal.
A VA abbreviated medical record for hospitalization from
January 5, 1992, to January 7, 1992, notes diagnoses of
adjustment disorder with depressed mood and alcohol abuse
episode. A January 5, 1992, VA medical certificate indicates
a diagnosis of schizophrenia. A January 5, 1992, VA clinical
record notes that the veteran was admitted with a diagnosis
of schizophrenia. A January 6, 1992, VA clinical record
history notes Axis I diagnoses of dysthymic disorder,
adjustment disorder with depressed mood, and intermittent
explosive disorder.
A VA hospital discharge summary for hospitalization from
November 15, 1995, to December 15, 1995, notes that the
veteran indicated that he had PTSD. The Axis I diagnoses
were adjustment disorder with depressed mood and borderline
personality disorder.
The report of a VA examination, dated in August 1996, notes
impressions of paranoid schizophrenia and PTSD. The examiner
commented that the veteran had both conditions that co-
existed, and that his psychotic symptomatology had a flavor
of combat experience in Vietnam.
Analysis
The pertinent provisions of 38 C.F.R. § 3.304(f) (1996)
require a clear diagnosis of PTSD. However, PTSD was only
diagnosed once and this diagnosis was in conjunction with
paranoid schizophrenia. Other medical records in the claims
file, particularly the reports of VA hospitalization, do not
show any diagnosis of PTSD. The 1995 VA hospital discharge
summary notes that while the veteran indicated that he had
PTSD due to his Vietnam service, no diagnosis of PTSD was
made. Since PTSD has only been diagnosed once in conjunction
with another psychiatric disorder, and there are no other
diagnoses of PTSD in the medical evidence, PTSD has not been
clearly diagnosed. 38 C.F.R. § 3.304(f) (1996).
Since PTSD has not been clearly diagnosed, a requirement for
establishing service connection for PTSD has not been
satisfied. Accordingly, the preponderance of the evidence is
against the veteran’s claim for service connection for PTSD.
38 U.S.C.A. § 1110, 5107 (West 1991); 38 C.F.R. § 3.304(f)
(1996).
ORDER
Service connection for PTSD is denied.
JACK W. BLASINGAME
Member, Board of Veterans' Appeals
NOTICE OF APPELLATE RIGHTS: Under 38 U.S.C.A. § 7266 (West
1991 & Supp. 1997), a decision of the Board of Veterans'
Appeals granting less than the complete benefit, or benefits,
sought on appeal is appealable to the United States Court of
Veterans Appeals within 120 days from the date of mailing of
notice of the decision, provided that a Notice of
Disagreement concerning an issue which was before the Board
was filed with the agency of original jurisdiction on or
after November 18, 1988. Veterans' Judicial Review Act,
Pub. L. No. 100-687, § 402, 102 Stat. 4105, 4122 (1988). The
date which appears on the face of this decision constitutes
the date of mailing and the copy of this decision which you
have received is your notice of the action taken on your
appeal by the Board of Veterans' Appeals.
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